Transformational Leadership and Nursing Retention: An Integrative Review

Aim To establish current evidence on the relationship between transformational nursing leadership and turnover intention. Background The persistent nursing shortage in healthcare has led to heightened demands for addressing both current needs and the healthcare requirements of a growing population. Recognizing the pivotal role of nursing leadership in fostering retention, this review highlights the influence of positive leadership on nursing staff. Evaluation. An integrative review, guided by Whittemore and Knafl's (2005) framework, was conducted using articles sourced from four online databases deducing to an inclusion of sixteen quantitative articles, one systematic review, and one integrative review published between 1992 and 2022. Key Issues. The study reveals conflicting evidence regarding the sole impact of transformational leadership on the nursing staff's intention to remain. However, it highlights transformational leadership's ability to enhance job satisfaction and organizational commitment contributes significantly to retention. Conclusion Using transformational leadership can effectively bolster nursing staff retention along with promoting other favorable workplace outcomes. Implications for Nursing Management. This review underscores the importance of enhancing leadership skills within nursing management. This involves not only fostering transformational leadership but also cultivating positive work-related outcomes to optimize nursing staff retention.


Introduction
Te global nursing shortage has become a prominent conversation in nursing and therefore nursing leadership needs to be diligent in identifying and advocating for change [1,2].Understanding leadership's impact on patient satisfaction and care is essential for achieving healthcare objectives [3].Patient safety outcomes rely on a positive safety culture cultivated by efective leadership to dismantle barriers to care [4].Various leadership styles, such as transformational, transactional, autocratic, and laissez-faire, have been studied.Nursing leadership signifcantly infuences retention by fostering positive leadership, healthy work environments, job satisfaction, and reducing negative work experiences [5].Nurse managers empower nurses through positive environments.Certain leadership styles, supported in the literature, promote work satisfaction and turnover intention mitigating absenteeism and increased psychological distress [6].

Review of the Literature
Nurse retention is a complex issue infuenced by various factors, including leadership styles, which can be situationally or organizationally rooted based on specifc nursing and healthcare demands [7].Leadership styles hold significant sway over a nurse's inclination to stay within an organization.Transformational leadership stands out as extensively researched across other disciplines and is considered the best-chosen style for healthcare leadership to encourage staf to provide profcient services with improved morale [8], thus, also producing positive outcomes for organizations, staf, and patients [9].Five measurable components characterize transformational leadership: behavioral idealized infuence, attributed idealized infuence, inspirational motivation, intellectual stimulation, and individualized consideration [10].Attributed idealized infuence refers to leaders who display confdence in ways that build respect.Behavioral idealized infuence involves discussing values and beliefs, specifying a sense of purpose and emphasizing the importance of a mission.Avolio and Bass [10] also suggest that inspirational motivation uses an energizing attitude for future optimism in achieving goals.Intellectual stimulation pertains to leaders who promote opportunities for professional growth [11].Finally, individual consideration focuses on the personal needs of each individual, especially those that are seemingly neglected [12].Such leaders empower and motivate professional growth directly through the provision of a positive environment [6].
Transformational leadership has been linked to improved patient safety, care satisfaction, and decreased adverse events such as medication errors [13,14].Crucially, it can mitigate nursing turnover by promoting intentions to stay at work [15].Tis "anticipated turnover" strongly correlates with actual turnover, serving as a reliable indicator of future attrition [16].Retaining experienced nursing staf familiar with unit operations positively impacts patient care outcomes [17], as their departure depletes valuable expertise, skills, and knowledge [7].

Design.
Guided by Whittemore and Knaf's [1] integrative review framework, this literature review followed their fve-stage process: (1) problem identifcation; (2) comprehensive literature search; (3) evaluation of the data; (4) data analyses; and (5) presentation of synthesized data.Te research question was developed using the PICO format which stands for patient, intervention, comparator (if relevant), and outcome [18].Te research question created was as follows: what is the relationship between transformational nursing leadership and turnover intention among staf nurses?

Inclusion and Exclusion
Criteria.Inclusion criteria are as follows: (1) articles must be written in English/translated to English; (2) must be peer-reviewed; and (3) study types must include qualitative, quantitative, mixed-methods, and systematic/integrative/scoping/literature reviews.Exclusion criteria are as follows: (1) opinion pieces, dissertations, thesis, grey literature, letters, and editorials.Te Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) fow diagram [19] search results are displayed in Figure 1.

Search Strategy.
Te literature search was carried out in June 2022, using four online databases including Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE via Ovid, ProQuest Nursing and Allied Health, and PubMed.Search terms were a combination of keywords reported in Table 1.

Search Outcomes and Extraction of Data.
Following the literature search, all citations were collected, uploaded, and stored in Covidence, a web-based platform used for conducting comprehensive literature reviews.Covidence is a software that helps streamline the reviewing process, facilitating the screening of citations, reviewing full-text articles, assessing the risk of bias, extracting study characteristics, and creating reports to export [20].Duplicates were removed using Covidence, followed by a manual review to ensure accuracy.All titles and abstracts were reviewed in conjunction with our inclusion criteria.When an abstract was not present, the study was read in its entirety to determine appropriateness.Full texts of studies were subsequently retrieved and reviewed again along with our inclusion criteria.As such, articles selected for data extraction were reviewed twice.Te quality of the data was evaluated on a 2-point scale examining empirical or theoretical rigour and data relevance.A log within Covidence was recorded to track articles selected for exclusion.

Data Evaluation and Synthesis.
As per Whittemore and Knaf [1], after the research identifcation and literature search have been performed, a comprehensive evaluation of the data must occur.While no specifed method for evaluating the quality of data exists, the recommendation is that it should be customized to the type of studies included [1].Journal Article Reporting Standards (JARS)-quantitative [21], JARS-qualitative and mixed-methods [22] criteria, and methods developed by Moher et al. [19] were used to analyze articles all articles included in this review.
During data analysis, studies were classifed based on the type of evidence and analyzed sequentially for similarities and diferences [1].Similar fndings were then compared and reduced into a succinct and manageable framework [1].Articles identifed through the quality assessment analysis as low relevance were excluded.After the data extraction process, two additional articles were removed due to a lowquality score not previously identifed, and the remaining articles were kept for inclusion.Included studies were manually reduced and entered into a summary table (Table 2).An iterative process was undertaken to examine data, noting patterns, and themes, depicting relationships, and cluster similar variables to draw comparisons [1].Patterns, commonalities, and diferences were identifed with frequent verifcation for accuracy to draw fnal conclusions [1].
Among the included studies, themes were observed examining transformational leadership and intention to stay/intention to leave/turnover intention, and actual turnover as well as between transformational leadership and 2 Nursing Research and Practice other variables including culture/climate of safety, organizational culture, organizational commitment, job satisfaction, and job stress.

Reported Scores.
Tree studies examined the disparities between staf nurses' perceptions of transformational leadership behaviors exhibited by nursing leaders and nurse leaders' own assessments of their transformational leadership behaviors.All three studies indicated that nursing leaders reported more frequent instances of transformational leadership than staf nurses did [28,29,32].Among these, Goh et al. [28] established statistical signifcance for this diference (ρ < 0.05).
In contrast to job satisfaction, additional research delved into job stress and burnout.Pishgooie et al. [16] unveiled a negative correlation between transformational leadership and job stress (r � −0.34, ρ < 0.001) and a positive connection between job stress and turnover intention (r � 0.34, ρ < 0.001).Teucksuban et al. [35] reported a negative association between burnout and intention to stay (r � −0.300, ρ < 0.01), with burnout elucidating 67.5% of the variation in nurses' intention to stay.While Ferreira et al. [27] could not discern a signifcant link between transformational leadership and burnout syndrome, their investigation into the separate facets of emotional exhaustion and cynicism revealed that transformational leadership tangibly and indirectly impacted these elements [27].

Intention to Stay.
Research has consistently shown a connection between transformational leadership and the intent to stay in the workplace [24,26,31,35,36] or a converse link with turnover intention [7,16,37].Cowden et al.'s [26] systematic review identifed a relationship between transformational leadership and the intent to stay, although one of their included studies did not achieve statistical signifcance.Lavoie-Tremblay et al. [37] found a strong negative prediction of nurses' intention to leave healthcare facilities (β � −0.14, ρ < 0.05), yet no signifcant prediction of nurses' intent to leave the nursing profession.Lyu et al. [31] established transformational leadership as a substantial predictor of intent to stay (β � 0.793, ρ ≤ 0.001).
Furthermore, various studies underline that nurse managers' leadership styles account for 12% of the variance in anticipated nurse turnover, with transformational leadership signifcantly surpassing other studied styles [26,34,38].However, Abualrub and Alghamdi [23] indicated that transformational leadership only accounted for 1% of the variation in intent to stay.Conversely, some studies suggest an insignifcant relationship between transformational leadership and intent to stay [6,23,25,30,33].
Brewer et al. [25] found that transformational leadership indirectly infuences intent to stay through organizational commitment and positive work environments.Goh et al.'s [28] study revealed that half of the surveyed hospital units showed a signifcant negative correlation between transformational leadership and turnover intention (ward A: r = −0.368,ρ < 0.01; ward D: r = 0.61, ρ < 0.01).Labrague et al. [6] echoed this, confrming a negative association between transformational leadership and organizational turnover intention (r = −0.080,ρ < 0.01).However, Kleinman [29] did not uncover a signifcant relationship between turnover intention and transformational leadership.
Transformational leadership also exerts an infuence on intent to stay through the mediation of other variables.Laing et al. [30] established a positive impact of transformational leadership on safety climate, indirectly infuencing intent to stay.Transformational leadership's positive indirect efect on intent to stay via the mediator of emotional intelligence was noted by Wang et al. [36] (β � 0.111, ρ ≤ 0.01).Lastly, beyond the intent to leave assessments, some studies analyzed actual turnover data.McDaniel and Wolf [32] found a turnover rate 5% lower than a magnet benchmark.Raup [33] observed actual nurse turnover to be 16% lower in units with nontransformational leadership.

Comprehensive Examination of Transformational Leadership and Retention.
A signifcant number of studies have investigated the relationship between transformational leadership and nurse retention, often in conjunction with other variables.Tese studies have revealed varying frequencies of reported leadership behaviors, raising questions about the efcacy of displayed transformational leadership [29].Nonetheless, despite these diferences, Lavoie-Tremblay et al. [37] and Pishgooie et al. [16] underscore the importance of involving both nurses and nursing leadership in the assessment of transformational leadership behaviors.Such inclusive evaluation ensures a comprehensive understanding of the contextual dynamics at play, enhancing the accuracy of conclusions.

Cultivating Positive Organizational Culture.
A positive culture within organizations can be gradually formed by leadership over time by systematically solidifying this culture through consistent transformational leadership behaviors [24].A favorable culture empowers nurses by providing opportunities for decision-making, professional growth, and confict resolution [24].By actively seeking input, promoting engagement in decision-making, and embracing shared participation [26], nurse managers cultivate an atmosphere characterized by cooperation and collaboration, thus nurturing a culture of support [7].Tis dynamic contributes to nurses' sense of commitment to their roles within the organization, ultimately bolstering retention.

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Transformational Leadership and Job Satisfaction.
Te positive infuence that transformational leadership behaviors has on nurses' career satisfaction is substantiated by several studies.As these transformational leadership behaviors look to support and coach nurses in their professional atmosphere, the transformational leader works to support a vision of nursing [32] and if this vision were to change, staf could report more dissatisfaction if they feel they need to change their vision to something they may not see as appropriate.Abualrub and Alghamdi [23] proposed that although job satisfaction may increase a nurse's intention to stay within nursing, it should be considered concurrently with other factors to maximize the potential to reduce actual turnover.Te interesting fndings of Pishgooie et al. [16] regarding job stress warrant attention.Nurses reported lower levels of job stress than anticipated, suggesting a potential adaptive response to their demanding environment.However, the correlation between job stress and anticipated turnover emphasizes that even seemingly resilient individuals can be vulnerable to the negative efects of elevated stress levels.If the two major indicators of job stress (role clarity and confict) become imbalanced, it can lead to the need to activate coping strategies, mitigate emotional exhaustion, and increase job dissatisfaction and anticipated turnover [16].Given the strong correlation between anticipated turnover and actual turnover, the assessment of anticipated turnover emerges as a valuable tool for gauging the potential for future attrition.[16].

Impact of Transformational Leadership on Retention.
While transformational leadership undoubtedly plays a pivotal role in retention [29], it may not have a large enough impact on a nurse's decision to leave the profession.Transformational leadership involves creating opportunities and adapting to organizational change to meet demanding needs [7].Te elements of transformational leadership are important to use for all nurses and are especially important to use as a framework to address the needs of novice nurses [7,37].Te structured support and mentorship embedded in transformational leadership practices are particularly benefcial for novice nurses, facilitating their professional development.Despite its undeniable relevance, it is important to acknowledge that transformational leadership, while impactful, may need to be complemented by other strategies to achieve signifcant reductions in both anticipated turnover and intention to quit.Tese measures are vital for mitigating potential consequences such as decreased productivity and increased organizational costs [27].
In summary, the extensive body of research underlines the central role of transformational leadership behaviors in nurse retention.However, this infuence is intertwined with a complex web of organizational, cultural, and individual factors.By embracing transformational leadership as a core principle while addressing these multifaceted dynamics, healthcare institutions can optimize nurse retention, ensuring a positive impact on both the organization and the nursing profession as a whole.

Implications for Nursing Management
To foster positive outcomes within the nursing organization, efective leadership skills are pivotal for both nursing staf and leadership members.Tese skills encompass profcient communication, the ability to infuence, inspire, and motivate others, and the facilitation of decision-making opportunities.Multiple studies emphasize the signifcance of robust nursing leadership training to cultivate transformational leadership behaviors that enhance nursing retention [6,16,24,26,27,34,36,37].For instance, Teucksuban et al. [35] highlighted the necessity for comprehensive training programs, encompassing areas such as transformational leadership methods, human resource training, and strategic planning, which contribute to the observed elevation in reported transformational leadership behaviors.However, it is imperative to align these behavioral changes with the organizational culture across all tiers [26], underscoring the pivotal role of leadership development programs in promoting favorable leadership behaviors and making sure that they ft well with the organization's values and beliefs.

Conclusion
In conclusion, the examined literature consistently revealed that nursing leaders often reported higher frequencies of transformational leadership behaviors than staf nurses.Positive links between transformational leadership and culture/climate, organizational commitment, and job satisfaction were evident, while job stress and burnout showed varying correlations.Transformational leadership exhibited connections with intent to stay, although this infuence was tempered by other variables.While transformational leadership plays a pivotal role in fostering retention, its impact may need to be complemented by other strategies.Further research is needed to comprehensively assess the impact of transformational leadership on nurse retention, thereby enhancing our understanding and promoting positive workplace outcomes.Te implementation of interventional studies, encompassing pre-and postevaluations of organizational outcomes, creates valuable insights for the design and refnement of nursing leadership training programs.
Te implications for nursing management are clear: leadership development programs are instrumental in promoting favorable leadership behaviors, but their alignment with the organizational ethos is crucial.Encouraging leadership training tailored to desired outcomes, fostering self-awareness among nurse leaders, and nurturing open communication channels are recommended strategies.By leveraging these insights, nursing leaders can not only enhance their own transformational leadership skills but also foster a positive workplace culture that contributes to nurse retention and, ultimately, the success of the organization.

Recommendations
Te implementation of self-awareness measures within nursing leadership could address the reported disparities in Nursing Research and Practice scores, given that self-awareness is a cornerstone of efective leadership [28].Proactive strategies to mitigate burnout syndrome should be created, including initiatives that acknowledge and appreciate employees' strengths [27].Te establishment of two-way communication models between nurses and nurse leaders, facilitating an open avenue for expressing concerns, adversities, and organizational issues, is recommended [35].Organizations are encouraged to tailor leadership training programs to their desired outcomes, recognizing the positive impact of transformational leadership on patient, professional, and institutional levels [27].
Te insights gained from this integrative review clearly demonstrate that nursing leaders are well-positioned to not only strengthen their own transformational leadership capabilities, but also institute measures that inspire a positive workplace culture and elevate nursing staf experiences.